“I heard a nurse say ‘If you die, it’s all your own fault'”. Ana, a 35-year old Filipino, looks down as she recalls the day she was brought to the hospital in a pool of her own blood. She had tried to induce an abortion.

The mother of seven, a survivor of domestic abuse, conceived most of her children by force. Poor and unable to care for them, she did not want more children.

But the government of the Philippines – a deeply Catholic state – imposes a blanket ban on abortion, even in cases of incest, rape or to save the mother’s life. It is one of the most restrictive laws in the world.

This does not stop women, like Ana, from undergoing over half a million procedures each year. Instead they take place underground, in murky backstreets, without professional oversight or sanitised equipment. Abortion drugs like misoprostol are widely available on the black market, along with traditional medicines and makeshift services. Ana opted for a “medical” intervention, where a catheter is inserted into a woman’s cervix for up to 48 hours.

One in six women who obtain illegal procedures in the Philippines suffer complications. Many of them die. While legal, even post-abortion services are limited and women often face prejudice and abuse by medical staff. But because abortion is criminalised, a culture of stigma and impunity prevails.

“I refused to be taken to the hospital,” explains Josie, another abortion survivor. “I was afraid that I would get imprisoned. I bled for more than a week.”

Millennium Development Goal 5 calls for a 50% reduction in maternal deaths and universal access to reproductive health by 2015. It is commonly known as the goal least likely to be fulfilled. Unsafe abortion accounts for 13% of maternal deaths – rising to 35% in certain regions. Most of these procedures are carried out in countries where abortion services are legally restricted.

According to research by the Center for Reproductive Rights, restrictive abortion laws lead to systematic abuses of women’s human rights – including the rights to life, health and equality.

“These are rights that are guaranteed very clearly under international treaty law,” says Melissa Upreti, the Center’s Regional Director for Asia. “So when a government denies access to safe and legal abortion they are essentially violating women’s rights.”

The Committee on the Elimination of Discrimination against Women has called on several countries, including the Philippines and Ireland, to liberalize their abortion laws. The UN Committee Against Torture described the blanket ban on abortion, reinstated in Nicaragua in 2006, as tantamount to cruel, inhumane and degrading treatment. Amnesty International described it as “a disgrace”.

In 2006, Colombian human rights lawyer Monica Roa successfully challenged the country’s total ban on abortion. The campaign, supported by Women’s Link Worldwide, was successful in large part because it managed to frame the abortion ban as a health and equal rights issue, rather than a religious or moral one.

They also chose not to bandy words with their most vocal opponent – the Catholic Church. “We decided not to engage with them, because we understood that it was not their decision to make,” says Monica. “We wanted to talk about what the state should do. And in a secular state like Colombia, and in countries, where there is at least freedom of religion and freedom of conscience, the state has to provide women with the freedom to make the decision whether to carry a pregnancy to term.”

But despite the clear implications for maternal health and growing body of human rights jurisprudence, the international development community has been reluctant to engage in the debate around abortion – even in extreme cases like the Philippines or Nicaragua.

All the major UN development agencies, including UN Women and the World Health Organization (WHO), have refused to condemn restrictive laws, despite implicitly recognising their harmful impacts on women. WHO has published vast guidance on safe abortion practices and added misoprostol to its essential medicines list in 2005.

“The UN agencies have been the worst,” says Monica. “It’s very problematic because many of them have a crucial role to play in implementing change in the lives of women.”

Political pressures have been substantial. In 2005, the Bush administration revoked funding from the UN Population Fund over claims that the organisation financed abortions. Despite reversing the decision in 2009, the current government has refused to endorse safe abortion as a human right. Except for Britain and Sweden, most governments share this stance. The mainstream focus remains on pregnancy prevention.

But the Center for Reproductive Rights maintains that it is impossible to address one without the other. “Any attempt to promote women’s reproductive health has to include integrated strategies for addressing all these issues,” says Melissa. “In order to address maternal mortality you have to address unsafe abortion and the legal issue is critical. The international community has to do more.”

There is often a correlation between abortion restrictions and low contraceptive use. In the Philippines, the Catholic Church is currently challenging a proposed bill to expand the availability of birth control.

Marie Stopes International emphasises the value of reaching out to local communities and moderate religious groups. “Religion can be empowering as well as restrictive,” says Louise Lee-Jones, Senior Manager. “There are many people out there with strong religious ethos who take a more liberal stance.”

She adds: “It’s important that any effort to liberalise abortion laws comes from within a country. It’s about positioning it as a health issue and working with local people to establish what they want.”

The key, agrees Monica, is untangling the moral binary and breaking the taboo. “One of the reasons we were able to win in the public debate, was to push it away from the black and white,” she says. “It is very important to have catholic women understand that the position from their religion is one thing, but they still have the right to make a separate decision.” A global NGO – Catholics for Choice – also works with partners across South America to send the message that you can be pro-choice and Catholic.

In the end restrictive abortion laws punish the poor, young and vulnerable, says Monica. And it is their voices that need to be heard. “If women with power and money had to have unsafe abortions the law would have been changed a long time ago.”